Thank you, medicalgrounds, for your suggestion. I've emailed our ID physician blog member to seek his response.
With regards to the H1N1 vaccination exercise, MOH has ordered a million doses of the new vaccine, of which 20% are set aside presumably for 'essential' government personnel. This translates to 200,000 doses at approximately $30 each, which comes to about $6 million, paid for by the government (excluding manpower and logistics/administrative costs).
H1N1 fatality rate: 0.007 to 0.045% (comparable, or less than an average seasonal flu according to the Reuter's report linked below).
Medifund disbursement for the needy (FY 2008): S$1.66 billion
Qn: What do you feel is the most prudent/cost-effective way of spending $6 million of taxpayer's money in light of the above?
a) Vaccinating all essential government staff (including low risk groups)
b) Vaccinating only essential government staff at risk of H1N1, save the rest of the money.
c) Spending the money on other healthcare initiatives (eg Medifund)
d) Others (feel free to elaborate)
References: http://sg.news.yahoo.com/cna/20091025/tap-650-singapore-receive-batch-h1n1-vac-231650b.html
http://www.reuters.com/article/healthNews/idUSTRE58E6NZ20090916
http://www.moh.gov.sg/mohcorp/hcfinancing.aspx?id=308
Thought I'd put this comment up as a separate post.
My thanks to DrFire for his/her input.
I trained in Canada and am now working as an attending here, having left Singapore in 2001 for med school. I think if Singapore switches to the US residency program, it will have to modify its medical school training to reflect the degree of clinical exposure that US/Canadian medical students get to the "system" even before graduating.
Here, in a 4yr program, the 3rd and 4th yrs are entirely clinical. The students are designated as clinical clerks. Typically they carry a maximum load of 4pts - and they are expected to know those patients in and out. They do an average of 1-in-7 call, which is less than the intern's average - but it is the same 36hrs of torture.
The Canadian system is similar to the US system except for the ACGME rules on work hours. There are no such rules here. The typical call is 1-in-4, 30hrs or so. But judging from what I've heard from my friends back home, the key difference has been that a lot of the scut that you guys deal with isn't something we had to worry about as much.
We have lab techs drawing the bloods, nurses starting IVs. Resp techs draw blood gases and can even intubate should the need arise. Don't get me wrong - you have plenty of chances to become good at doing all these things, since you are expected to do these throughout the senior years of medical school. And in the intern year, you're called if - God forbid - the techs/nurses are unable to obtain the line or gas. You get first dibs on all procedures - but after the 100th IV you've placed, it is a huge help to have ancillary staff who can look after the scut, who don't view it as scut.
Is this system better? I don't honestly know. What I do know is that I am happy that I finished my residency when I was 26, passed my boards at 27 and I don't feel the worse for having done it the unconventional, quick route. But the biggest issue I foresee with changing Singapore's UK-based system into a US-based residency is that one must be very careful as to how it is done, especially taking care that the medical curriculum is also changed to provide medical students with greater clinical exposure.
I would say that when I was going through clerkship, chatting with my friends gave me a greater appreciation of just how vastly different the two systems are. In the 5th yr in a UK med school, they were placing IVs - by the end of my 3rd year, I had placed IVs, 3-4 central lines, arterial lines, and more.
Did that make me better-trained? No. The expectations of our respective training models were different. In the end, it is not an issue of which system is better, but more an issue of whether the training is adequate for what lies ahead. To implement a residency system for which the medical student has not been prepared would be dangerous and a disservice to one's training, I believe.
Just my two cents' worth.
1) Doesn't know the actual names of the medications s/he takes.
2) Thinks telling the doctor, "It's a round, white pill" actually helps.
3) Tolerates even the most severe symptoms ( e.g. chest pain ) till the weekend or public holiday period is over before flooding the clinics and ERs, hence the dreaded Monday surge.
4) Has lots of concerned relatives who don't communicate with one another and hound you constantly for repeated updates.
5) Has relatives who would rather spend 15 minutes chasing nurses than bring the patient to the toilet themselves.
6) Signs consent forms for procedures and retains less than 50% of the information given.
7) Thinks by taking diabetes / hypertension / hypercholesterolemia meds, this entitles him/her to eat whatever the heck s/he wants.
8) Thinks waiting an hour warrants a letter to the Forum Page.
9) Thinks the Forum Page is a great way to scare healthcare workers.
10) Assumes that "all my medical records are in your computer, what."
It was reported last week that Dr Martin Huang - a well known plastic surgeon - was fined $5,000 and censured by the Singapore Medical Council for injecting animal fetal cells into his patients (a dubious and unproven practice). It appears that he was caught only because he was foolish enough to "advertise" this in a health and beauty magazine (therefore who knows how many out there are doing the same). This was further touched upon by no less than the Director of Medical Services in the MOH blog, which fell just short of accusing Dr Huang of not having his patients' interests at heart.
Another reader has submitted a topic for discussion on Singapore MD:
"I received a letter from MOH the other day outlining DMS' vision for transforming postgraduate medical education. It ended with a call for participation in dialogue sessions.
I threw the letter away.
The fact that MOH has decided to hold dialogue sessions only after all the major decisions have been made only goes to show that MOH deals with our professional body in a paternalistic manner. Dialogues inevitably end up becoming monologues. Little wonder why MOH's initiatives rarely gains any support from the ground.
If I may suggest, perhaps, we can have a discussion on what it would take for MOH to gain the confidence and support of the body of physicians that it needs to work with, rather than dictate to."
angry doc
I tend to agree with our contributor's observation - I just yesterday received a letter from MOH informing me that the planned amendment to the Medical Registration Act will pretty much carry on: SMC will still have "the option" of appointing a legally-trained person to a disciplinary tribunal, except that now that person may be appointed as either the chairperson, or as a voting member.
How this round of "dialogue" will alter the plans for a new training system I do not know, but I am keen to attend one of these sessions just to get a ground feel.
See you all there.
Interesting how a topic about service quality vs cost veered off on a tangent.
So with the raging debate about doctors in general "earning too much", what say you about the salary discrepancy within the medical community, i.e. between the public and private sectors?
Should those in private practice be viewed any less favourably than their counterparts in public institutions?
Is it considered wrong for doctors to treat affluent patients exclusively when so many others belong to the lower income brackets?
I always wonder about those medical school interviews, when candidates are asked, "Why do you want to become a doctor?"
You can expect the usual spiel about "wanting to help my fellow human beings, comfort the sick, ease suffering, etc."
While it's true that you can do all this in a private setting, your clientele would differ quite significantly from those visiting restructured hospitals.
Your comments, please.
NUH nurses play Facebook game at work
What message is the person who posted this photo trying to convey?
1) That healthcare workers aren't entitled to some R&R during downtime, and should instead stare into space and let their minds go blank when there's nothing to do - and probably be accused of slacking off as a result?
2) That certain people like to sneak around counters with the hope of catching HCWs in compromising positions? ( I'm told this picture can only be taken if you walk all the way round to the back, which is not what a normal visitor would do. )
And now it seems the nurse has been disciplined by NUH.
What message does THAT convey?!
Thank you to An Old Friend, who contributed this topic suggestion.
"Hi moderators, wondering if we could have a discussion on The Practice of Medicine (eg Parson's Sick Law) vs Service Quality and Standards (eg ISO) vs cost and the conflicts they present?
Personally I feel that the delivery of medicine is not the same as the delivery of service in other industries, eg hospitality or airlines.
Secondly, the expectations and cost factors.
For example, while there is always this drive towards "service excellence" in every organization, the quality of the service is different depending on the price you pay for that service. However the management do not look at it that way. They look into every complaint in the same way in every organization. It seems to be left to the customer to decide what his expectations will be (sometimes this can be tempered if he is paying a low price). But it seems that in healthcare, free seems to be the price everyone wants to pay so no luck having any pared down expectations subsidized or not.
Case in point. How do the management of SIA and Singhealth weigh their quality standards? I bet they both want "service quality excellence". I don't see SIA rates being cheap though. Same with ShangRi-La Hotels.
It is extremely difficult if the government does not control the expectations of the people when it comes to subsidized healthcare, and yet want to control cost. The system is extremely taxing on the staff who provide the service. They are sandwiched between trying to give "world class service excellence", but keeping costs low."
spacefan
I will post my reply first. Perhaps the rest of the panel can add their comments by editing this entry.
I fully agree that healthcare in Singapore has a distinct slant towards service provision, and that patient expectations aren't being managed sufficiently.
Conversations with people from the United States, Canada, Australia and the United Kingdom reveal a very different mentality - they understand the constraints of the public healthcare system based on how much less it costs the consumer.
The ER is a common discussion point - partly because I'm an ER physician. I recall a Canadian couple who recounted an 8-hour wait to consult a doctor about an elderly mother's hip fracture. When I told them an 8-hour wait in our ERs will guarantee a major riot - not to mention a reprimand from MOH, followed by interventional measures - they looked shocked and described this as "grossly unreasonable", especially after I told them we see an average of 400 cases a day, about twice the ER attendances in these countries.
The same goes for Americans and Brits. They know what to expect and usually kick up a fuss only if mismanagement is involved.
One might argue that since the Canadian and UK governments provide free healthcare for its citizens, patients have no cause for complaint.
But Singaporeans also receive substantial subsidies, and have easy access to tertiary hospitals where high-quality medical expertise and technology are readily available ( unlike rural areas in larger nations ).
Even a B2-class patient can be listed for an elective operation within weeks, compared to someone in the UK who waits an average of 12 months for a routine hernia repair or cholecystectomy.
The definition of "service excellence" varies according to the individual. For some, waiting time is a huge factor ( and one of the most important key performance indicators across the board ), while others may pay more attention to, say, the staff's demeanour.
But there's no denying that few subscribe to the idea that "the quality of the service is different depending on the price you pay for that service". In my 10 years within the public sector, I've encountered numerous patients ( and relatives ) who demand a level of service which is better accomodated in a private institution. But when I suggest they seek an opinion at such hospitals, they retort, "Why should I pay more?"
They want immediate scopes, cardiac scans, MRIs, consults with senior specialists. They criticize our "ridiculous policies" of arranging early clinic appointments, even for clearly non-urgent conditions. They start screaming bloody murder when they don't get sent to the ward within 2 hours, even when we explain that the hospital is full and beds can only be emptied when patients are discharged.
Is it because the government isn't controlling the people's expectations? Perhaps, to some extent, this is true, and is reflected by how MOH prioritizes its list of KPIs. After all, waiting times do nothing for a doctor's frazzled psyche, and only serve to pacify and impress the consumer.
The media also plays a part, regularly churning out statistics comparing one hospital / polyclinic with another. Let's not forget the dreaded Forum Page, which every HOD / CEO pores through first thing in the morning, hoping s/he won't see his/her department or institution fingered in a complaint letter which may / may not contain reliable facts.
The evolution of healthcare towards a service industry was probably also accelerated by marketing efforts that trumpet Singapore as THE centre for world-class medical care, including public hospitals in the mix. How much this has affected local perceptions, however, is hard to say.
I wouldn't go so far as to state that "in healthcare, free seems to be the price everyone wants to pay so no luck having any pared down expectations subsidized or not." I do ( occasionally ) meet patients who demonstrate a good understanding of our limitations - and it's no coincidence that many hail from the older age and lower income groups.
Based on personal experience, the majority of those who voice dissatisfaction are the well-educated, more affluent and younger people. I'm especially wary of those who come armed with information from the Internet or "a doctor friend / relative" or "a friend / relative who also has this condition or knows someone who does".
Another contributor to unreasonable expectations? Whether it's deliberate or not, I've had GP referrals asking me to arrange scopes / MRI scans / consults with specialists the very same day the patient comes to the ER.
You can see how this causes problems when the patient thinks I'm trying to pull a fast one, since his/her family physician of XX years, whom s/he trusts whole-heartedly and who can do no wrong, is being contradicted by this idiot of an ER physician.
Anyway, I'm nowhere as good as Angry Doc and Gigamole where in-depth analysis is concerned. Just offering a view from the trenches.
angry doc
This is not really a 'medical' issue, so I can't claim that my analysis is an accurate one...
There are a few issues being brought up here, from the question of cost and affordability, to quality of "service", and also timeliness of access to care. People want "Better, Faster, Cheaper", and it seems that no one is willing to tell them that they can't have all three.
Good healthcare requires considerable resources, and since resources are limited, healthcare must be rationed. Longtime readers of my blog will know that I used to be an advocate for rationing by needs and not means, but over the years I have changed my views on the topic.
My current views on the topic are set out in the comments section of this earlier post.
Put simply, subsidised healthcare not backed by the moral courage to demand accountability from patients distorts the true value of healthcare and is ultimately destructive to the morale of its providers. We are in the state we are in today because the public thinks they can dictate what resources they wish to consume from the system based solely on the fact that they hold a ballot, and no one tells them otherwise.
Many doctors remain within the public system because they have no choice - they are either bonded or under traineeship - and others remain because the public sector offers them things of value which they cannot obtain in the private sector, such as research or teaching opportunities. No one, however, chooses to stay so they can be told how to do their jobs by laymen. Whatever the reason, as long as we choose to remain in a subsidised healthcare system where laymen's "concerns" are allowed to override our clinical opinions, we are helping to perpetuate it.
I will end by repeating the quote I posted in the earlier thread:
"I observed that in all the discussions that preceded the enslavement of medicine, men discussed everything—except the desires of the doctors. Men considered only the 'welfare' of the patients, with no thought for those who were to provide it. That a doctor should have any right, desire or choice in the matter, was regarded as irrelevant selfishness; his is not to choose, they said, only 'to serve.' That a man who's willing to work under compulsion is too dangerous a brute to entrust with a job in the stockyards—never occurred to those who proposed to help the sick by making life impossible for the healthy.
I have often wondered at the smugness with which people assert their right to enslave me, to control my work, to force my will, to violate my conscience, to stifle my mind—yet what is it that they expect to depend on, when they lie on an operating table under my hands? Their moral code has taught them to believe that it is safe to rely on the virtue of their victims. Well, that is the virtue I have withdrawn. Let them discover the kind of doctors that their system will now produce. Let them discover, in their operating rooms and hospital wards, that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of man who resents it—and still less safe, if he is the sort who doesn't."
We've seen a surge in the number of visitors to this blog these past few weeks, mainly the result of lively discussions of hot topics close to readers' hearts.
Thank you for sharing your views with us, and especially with regard to the residency programme issue, I hope all concerns expressed have reached those with the power to do something about them.
Singapore MD was launched only 5 months ago, but thanks to an outspoken panel of contributors, an increasing number of followers, and referrals from other traffic-heavy websites, it appears we're gaining a good momentum.
For me at least, comments from readers motivate me to post more entries. And my fellow writers' choices of current and occasionally controversial subjects keep things very interesting.
On this note, I'd like to make a suggestion to our readers: if you have any topics you'd like to have discussed on this blog, or any burning questions to ask its contributors, feel free to leave a comment or drop us an email. If you choose to contact us via the latter route, please rest assured that your identity will be kept in the strictest confidence.
Bear in mind, of course, the disclaimer posted on the left.
I look forward to seeing what happens. :)
hi, could you please post this up on singaporemd. These are two articles written by a friend of mine who is a final year medical student. I think it pretty much sums up the desperation some of us are feeling now. Not everyone in the class is against the residency programme, which in fact makes those against it worst as now our class is totally divided, hence we are unable to stand up against the DMS.
(links deleted per author's request.)
Thanks.